Small business health insurance 07

Substance Abuse in Rural Pennsylvania: Present and Future
Laurie Roehrich, Ph.D., William Meil, Ph.D.,
Jennifer Simansky, M.A., William Davis, Jr., M.A., and Ryan Dunne, M.A.
This project was sponsored by a grant from the Center for Rural Pennsylvania, a legislative agency of the Pennsylvania
The Center for Rural Pennsylvania is a bipartisan, bicameral legislative agency that serves as a resource for rural policy
within the Pennsylvania General Assembly. It was created in 1987 under Act 16, the Rural Revitalization Act, to promoteand sustain the vitality of Pennsylvania’s rural and small communities.
Information contained in this report does not necessarily reflect the views of individual board members or the Center for
Rural Pennsylvania. For more information, contact the Center for Rural Pennsylvania, 200 North Third St., Suite 600,Harrisburg, PA 17101, telephone (717) 787-9555, fax (717) 772-3587, email: [email protected]
The focus of this project was to study the current status and
trends in substance use and treatment in rural Pennsylvania tobetter understand present needs for prevention and treatment
programs, and to make recommendations regarding future
needs. To do so, the research team reviewed current trends inalcohol and drug use in rural areas of the state, reviewed
literature on the cost effectiveness of drug and alcohol treat-
ment, reviewed model science-based treatment and prevention
Substance abuse rates and trends in rural
programs, and surveyed rural treatment providers and ruralSingle County Authority (SCA) members across the state. The
team also created a treatment center directory for all rural drug
and alcohol facilities across Pennsylvania.
From their review of current trends in alcohol and drug use in
rural areas, the researchers found data indicating that tobacco
use is higher in rural areas, and that alcohol and drug use may
be higher among rural teens when compared to urban teens.Recent data also show high school seniors in Pennsylvania
Single County Authority (SCA) survey . 1 0
drink, smoke, and use other drugs more than their counterparts
across the country. Perhaps most alarming is the rate of binge
drinking reported among these students, a behavior typicallyhighest among those in rural areas. The data also show that rural
communities are worried about methamphetamine and heroinuse and that the use of OxyContin and other pharmaceuticalshas increased and appears to be somewhat more concentrated inrural areas.
In terms of cost effectiveness of treatment, the researchers
found that even brief outpatient treatments appear to signifi-cantly decrease costs to the individual and to society as awhole. Compared to many other types of health care interven-tions, alcohol and drug abuse treatments are significantly lessexpensive than most medical procedures.
The researchers also found that there are a large number of
both treatment and prevention intervention methods currentlyin existence, which are science-based and widely considered tobe effective. However, it is important to note that, to date,almost none of these interventions have been researched in ruralareas, including Pennsylvania. This is one area where the statecould be collecting data to determine how best to use thesemethods in rural settings.
The survey of SCAs and treatment centers in rural Pennsylva-
nia also yielded interesting results. The SCA survey indicatedthat barriers exist to substance abuse prevention and treatmentprograms in rural areas and there was uncertainty amongrespondents about the prevention and treatment services intheir communities and the adequacy of funding for the services.The survey of treatment centers helped the researchers to createa profile of providers in rural Pennsylvania and found that theretention and recruitment of treatment center personnel willdepend highly on continuing education and training andadequate compensation.
• Low population density may result in a lack of treatmentcenters, funding, and specialists;
The focus of this project was to study the current status
• The distance rural clients must travel may be considerable;
and trends in substance use and treatment in rural Pennsyl-
• A lack of trained professionals may result in decreased
vania to better understand present needs for prevention and
availability of treatment and potentially inadequate or
treatment programs, and to make recommendations regard-
ing future needs. The Center for Rural Pennsylvania’s 2004
• Rural clients’ reluctance to disclosure personal informa-
attitudinal survey of rural Pennsylvanians shows that drug
tion and find treatment in a small community for privacy
and alcohol (D&A) abuse is one of the issues rated most
highly among rural Pennsylvania residents as needing
• Conflict between enrollment in a treatment program and
higher priority in the years ahead. Sixty-four percent of
respondents to this survey indicated D&A abuse required
Operating hours of treatment facilities and client work
greater attention in the future. In response to another
schedules are typically the same, so if the distance between
question, 49 percent of respondents said a future priority for
the two are great, conflicts may exist. In addition, Campbell
the state should be “strengthening programs to deal with
et al. (2002) discuss the difficulty in attracting and funding
drug and alcohol abuse” (Willits et al., 2004). In general,
mental health providers and services in isolated areas and
people in rural areas, when compared to urban populations,
note that there is less likelihood of medical insurance
have been found to experience higher poverty rates, more
coverage for rural residents and a lack of information
geographic barriers, greater isolation, fewer telephone and
available about various entitlement programs. According to
transportation options; are less likely to possess health
the federal government’s Substance Abuse and Mental
insurance or information about entitlement programs; and
Health Services Administration’s (SAMHSA) website,
have fewer employment opportunities (American Psycho-
flawed views of rural America also represent a significant
logical Association, 2002). These variables suggest that
barrier for these communities, and this inaccurate picture
many significant barriers to treatment are already present in
results in an underestimation of how much funding and
rural areas. Moreover, substance abuse should not be viewed
services are really needed to effectively run treatment
as an urban plight. Drug and alcohol problems are wide-
spread across all areas of the nation and state. Given thatmore than 70 percent of Pennsylvania’s counties are
designated as rural, according to the Center for RuralPennsylvania’s definition that is based on populationdensity, creating and maintaining a network of accessible,
This research pulled data from a number of resources to
affordable, well staffed and successful D&A prevention and
understand the current treatment system in Pennsylvania
treatment programs should be a priority (Harwood, 2000).
and predict how to best prepare for the future.
Data from the American Psychological Association (APA,
The project, conducted in 2004 and 2005, included an
2002) indicate that across the U.S., more than half of all
extensive review of current and predicted trends in alcohol
rural counties are not served by a psychologist, psychiatrist
and drug use, a literature review of cost effectiveness data
or social worker. In Pennsylvania, the State Health Improve-
and reviews of model treatment and prevention programs.ment Plan Special Report and Plan to Improve Rural
The research also entailed two surveys: one of SCA mem-
Health Status notes that 16 of the 22 mental health profes-
bers and one of rural alcohol and drug treatment center staff
sional shortage areas in Pennsylvania are in rural counties
(clinicians and directors) to find out more about their
(Pennsylvania Department of Health, 2000).
There are substantial gaps in the research on substance
abuse treatment and prevention in rural areas. Empirical
inquiries that have been published are subject to method-ological issues, such as inconsistent definitions of rural,inadequate generalizations of results from urban to rural
Substance abuse rates and trends in rural
areas, and sampling methods that do not accurately repre-
sent rural areas. All of these methodological shortcomings
To understand substance abuse trends in rural Pennsylva-
serve to render comparisons to rural Pennsylvania question-
nia, the researchers examined the results of several national
and state surveys, and reports from law enforcement.
There are countless numbers of substance abuse surveys
administered at the national, state and local levels through-
Despite variability across rural communities, some of the
out the country. The findings reviewed here come from the
barriers that rural residents face in finding and participating
Monitoring for the Future Study, the Pennsylvania Youth
in treatment for substance abuse appear, for the most part, to
Survey (PAYS), the National Survey on Drug Use and Health
be universal. Booth et al. (2001) have identified five barriers
(NSDUH), and the Drug Enforcement Administration (DEA).
to treatment that rural residents face:Substance Abuse in Rural Pennsylvania: Present and Future
The conclusions reached below are a general rank
ticals have shown recent increases in use. Use of diverted
ordering of the dangers represented by various drugs being
pharmaceuticals in Pennsylvania is also high and shows
used. Several variables were considered in this ranking,
similar rates to those observed nationally. The use of these
including the degree of use both nationwide and in Pennsyl-
drugs appears somewhat more concentrated in rural areas
vania, changing trends in use, the toxicity and addictive
and the number of treatment admissions for their use has
liability of the drug in question, and the degree to which it
been rising in Pennsylvania, where law enforcement views
represents a greater concern for rural communities both
it as moderately to highly available.
7. Recent data show high school seniors in Pennsylvania
1. Alcohol represents a major public health concern
drink, smoke, and use other drugs more than their counter-
because of its widespread use and the social and health
parts across the country. They are also more willing to try
related consequences of that use. Continued vigilance
alcohol and drugs, and drive under the influence of
regarding alcohol abuse in Pennsylvania is especially
alcohol or marijuana than 12th graders nationally. Perhaps
warranted as it is the most commonly used drug among
most alarming is the rate of binge drinking reported
the state’s youth and use levels are above those seen
among these students, a behavior typically highest among
nationally. Moreover, alcohol use and associated prob-
lems should be of particular focus in rural areas where use
8. Marijuana use is widespread, though it has shown
rates are highest on some measures, such as binge drinking.
recent decreases in Pennsylvania and nationwide. In
2. Like alcohol, tobacco products remain a substantial
Pennsylvania, marijuana use ranks third among the drugs
problem because of their degree of use. While both
used by adolescents, yet statewide use appears to be
cigarette and smokeless tobacco use have shown recent
below the national average on most measures. While
declines, the decreases appear to be slowing (cigarettes) or
readily available, though perhaps less in rural areas,
have stopped (smokeless tobacco). Cigarette smoking in
marijuana is viewed by law enforcement as less of a threat
Pennsylvania is the second most common drug used by
youths and their use is above the national average across
9. Inhalants are emerging as a class of drugs. They are the
most age groups. Given that both cigarette smoking and
one of the few drugs showing the clearest evidence of
the use of smokeless tobacco products show higher levels
increased use in recent years. Moreover, leading indica-
of use in rural communities, the use of tobacco products
tors of continued use, such as perceived risk, suggest this
within rural regions remains a point of considerable
trend may continue. Use of inhalants currently ranks fifth
in prevalence among Pennsylvania’s youth. Moreover,
3. Heroin use has been relatively low and stable across
inhalant use among rural communities is as high as in
population densities for the last few years. However, it is
viewed by law enforcement as the number one drug threat
10. The threat posed by “club drugs,” like ecstasy and
in Pennsylvania. Heroin appears to be readily available
GHB, is serious, but less than the dangers associated with
throughout the state and has recently become responsible
heroin, cocaine, marijuana, diverted pharmaceuticals, and
for a growing number of treatment admissions in the state.
methamphetamine, according to the DEA. The rate of
Once an urban problem, heroin can now be found causing
ecstasy use has been declining and its use does not appear
problems in many communities across the state.
to pose a greater threat to rural communities than to other
4. Methamphetamine has shown some recent declines in
use nationally, but its spread across Pennsylvania is of
When trying to make predictions regarding trends in rural
growing concern. Production is greatest in rural regions of
drug use in Pennsylvania there are several factors to be
the state and many believe its spread from rural regions,
taken into account. The first is that there is no single study
especially the Northwestern corner of the state, is immi-
that provides data directly examining rural versus urban
nent. Methamphetamine is of grave concern both because
differences in use across regions of Pennsylvania. Perhaps
of its harmful effects on the user and the dangers associ-
the most relevant data that exists comes from the PAYS
study and it does not allow for direct comparisons of use
5. Cocaine and crack cocaine use remain relatively stable
across population densities. Furthermore, this study is
and lower than in the later part of the last decade, though
limited to adolescents and fails to consider differences that
some data suggest their use may be increasing among the
may occur across life spans. In addition, there is little
state’s youth. However, it now appears that rural commu-
consistency between the definitions of various populations
nities are more susceptible than ever to the problems
between the available sources of information. Thus the
posed by cocaine and crack cocaine. Law enforcement has
conclusions of this report, stated earlier, regarding trends in
designated cocaine as a drug of major concern because of
rural substance use are based on projections from a variety
its availability and extent of use. The degree of threat
of sources and assessments made by law enforcement.
posed by cocaine and crack is magnified by the violence
Acquisition of data that directly addresses rural versus
associated with the cocaine and crack trade.
urban drug use differences in Pennsylvania will greatly
6. Nationwide OxyContin and other diverted pharmaceu-
improve the ability to predict trends in the future.
Review of literature on cost effectiveness
would be a large scale, expensive, and time-consuming
Attempting to prove whether or not alcohol and substance
enterprise for Pennsylvania. But, later savings and improve-
abuse treatment is a solid investment is typically measured
ments in the treatment delivery system would offset the
costs of such a project. In the meantime, it should be noted
First, some studies concentrate on cost effectiveness.
that when cost analysis has been performed at either single
Outcome measures are typically not defined by dollars and
sites or throughout entire states (California, Oregon), using
cents but by significant improvement on variables such as
cost effectiveness, cost benefit, or cost offset approaches, the
alcohol and drug use, legal problems, employment status,
results are quite encouraging. No matter how it is measured,
mental health status or physical and medical problems. It is
treatment appears to be a wise investment.
assumed that improvement on these outcome variables is
One of the most widely noted projects is known as
associated with decreased costs to society, but these
CALDATA (Gerstein, Johnson, Harwood, Fountain, Suter, &
changes are not directly quantified. If two (or more) treat-
Malloy, 1994), a large-scale study that took place across the
ment approaches result in similar positive client outcomes,
entire state of California. The study is especially notable
this would suggest that providers could safely opt to
because the clients who participated in the research were
whichever treatment intervention is cheapest to deliver.
randomly chosen. This significantly decreases the possibil-
The second body of literature, referred to as cost benefit
ity of over sampling persons who are motivated, doing well
studies, uses outcomes that are translated into monetary
and remaining in treatment. The study took place in 16
scales. These studies often focus on outcome measures, such
countries, involved 97 different treatment centers, and
as reductions in crime and victimization, productivity in the
enrolled 1,850 clients, some of whom were followed for up
workplace, criminal justice expenditures, or in benefit
to two years. The California system of alcohol and sub-
programs such as welfare or disability.
stance abuse treatment is the largest in the nation. Authors
The last branch of research is a type of cost benefit study,
estimated the cost of treating the approximately 150,000
but the emphasis is placed on outcome measures that
clients seen in 1992 at $209 million. But, benefits to the
estimate savings in the area of health care expenses. This
taxpaying public totaled over $1.5 billion in savings. One
research is generally labeled as a “cost offset” study.
day of treatment pays for itself, primarily through reduc-
No matter which approach is taken, most studies require at
tions in crime. Depending on the type of treatment (outpa-
least one year’s worth of data for comparisons and standard-
tient, residential, and specialty opiate specific treatments
were studied) the benefits of treatment outweighed the cost
Each of the approaches described above requires data
by a 4:1 ratio (residential), to as high as 2:1 (methadone for
about the cost of treatment. Treatment costs include the
opiate users). Benefits following treatment extended across
expense of delivering the services by qualified staff and
the two-year period. Keep in mind that all of these studies
providers, and the cost of services that are reimbursed by
calculate costs/benefits generally over one to two years;
health insurers. A national sample of providers shows wages
thus, lifetime savings would be even more impressive
and salaries for treatment personnel to account for about
estimates. Overall, CALDATA research noted an average $7
half of the total costs of treatment, and administrative and
return for every $1 dollar spent on treatment.
maintenance expenses to account for about one quarter of
One recent comprehensive review of the substance abuse
the costs (CSAT, 2001). These primary budget expenditures
treatment cost effectiveness literature (Harwood, Malhotra,
are generally far higher than costs for facility rental or
Villarivera, Liu, Chong, & Gilani, 2002) included 58
purchase and depreciation (estimated at 5 percent), utilities
studies. The authors concluded that there is not a very
(4 percent), or medical and laboratory costs (3 percent). It is
strong body of evidence, employing good scientific
important to keep in mind that for the majority of treatment
methods and rigorous study designs, indicating that
programs in Pennsylvania, as well as in other areas, the most
receiving some or any treatment is better (and preferable)
common type of staff expenditure is for counselors, includ-
than receiving none, but that the economic benefits signifi-
ing certified addiction counselors (CACs). In general, these
cantly outweigh the costs of providing treatment. Invest-
staff members are paid on a significantly lower scale than
ment returns on $1 of treatment generally ranged from $4 to
other types of health professionals, such as nurses, physi-
$14, depending on the level of care and type of alcohol/
cians, or psychologists (who comprise only about 5 percent
of the personnel expenditures in substance abuse treatment).
The second task of Harwood et al. was to explore the cost
This suggests that there may be a limit to how low expendi-
effectiveness issue – are some treatments better than others
tures can go, given that the lower-paid CACs are the current
and also cheaper to deliver? The alcohol and substance
workhorses of most treatment centers.
abuse treatment system throughout the U.S. is based on a
When compiling studies and publishing research litera-
levels-of-care model that was designed by the American
ture for this report, no studies were located that used
Society of Addiction Medicine (ASAM, 2004). ASAM
Pennsylvania as a study population, and only several
provides two sets of guidelines, one for adults and one for
projects (with data collected in other areas of the U.S.) made
adolescents, and five broad levels of care for each group.
any comparisons between rural and urban populations. This
Within these broad levels of service is a range of specific
Substance Abuse in Rural Pennsylvania: Present and Future
levels of care. This model, which is used as the standard in
with additional mental health problems or cognitive
Pennsylvania, emphasizes using outpatient services
deficits, and clients with additional health problems such as
whenever possible, and limiting residential and inpatient
HIV. However, no studies have directly addressed the
stays to shorter durations. Most data suggest that outpatient
variable of urban versus rural populations, and it is worth
treatment, and in one study even the more costly outpatient
noting that most of the large multi-site trials displaying the
detoxification services (Hayashida, 1989), are effective and
effectiveness and utility of the Project MATCH manuals and
cheaper than inpatient stays. Pennsylvania’s Intensive
treatments were conducted in larger urban areas. However,
Outpatient Programs (IOPs) have not been studied. However,
the nine data collection sites were dispersed across the
this program also advocates effective treatment for less
nation, suggesting that the effectiveness of the interventions
money than an inpatient treatment episode. For many
was not limited to any particular geographic region.
clients, it is also preferable because they can remain at home
Approaches developed primarily for the treatment of
or work during the evenings rather than living in a hospital
cocaine (and now methamphetamine) addiction include
Cognitive-Behavioral Therapy (Carroll, 1998) and Commu-
One final question explored by Harwood and colleagues
nity Reinforcement (also referred to as Contingency
was treatments for special populations. The research found
Management; Higgins et al., 1991, 1994). Both of these
that women benefited from treatment as much as men, with
interventions have been studied in depth by the National
cost benefits slightly lower due to women’s lower crime
Institute of Drug Abuse and have been found to be effective
rates both during and after treatment. Veterans, treated at the
strategies. As with Project MATCH, the majority of projects
Department of Veterans Affairs system, have been exten-
were centered in more urban areas and rural centers have not
sively studied, and this research led to changing most 28-
day programs to 21 days. The longer stay did not create
Relapse Prevention (Marlatt & Gordon, 1985) is an
enough additional improvement to warrant the costs. The
approach that can, and has, been used with all types of
study of clients with dual diagnoses has played a major role
alcohol and drug problems, as well as with gambling
in the development of case management services and
disorders and smoking cessation. It has been shown to be
Mentally Ill Substance Abuser (MISA) programs. Both of
effective in medical settings and outpatient clinics both in
these approaches are used in Pennsylvania and appear to
the U.S. and beyond. The intervention rests on the assump-
result in reduced hospitalizations (cost reduction). For those
tion that relapses can occur almost automatically, without
with the most severe problems, residential therapeutic
conscious intent, unless the client is trained to look for
community (TC) placements may also be useful in symptom
warning signals and employ strategies to help avoid or cope
improvement and reducing high expense health costs such
with situations, emotions, and even locations where alcohol
as emergency room visits. Lastly, the authors reviewed
prisoners/offenders receiving treatment in jail or prison, and
Harm Reduction (Denning, 2000; Marlatt, 1998) is a more
drug court data. These two approaches were both found to
controversial approach because it recognizes that some
be highly cost effective and to result in lower rates of
clients may not initially be ready or capable of complete
substance relapse and lower rates of criminal recidivism.
abstinence. However, the argument for Harm Reduction is
Pennsylvania currently has fewer than a dozen drug courts,
that even decreases in use can lead to improved quality of
and may want to expand this option given the promising
life, better public health and reduced crime, and many
data in this area. Overall these findings suggest that special
clients who begin in this modality eventually move towards
populations also benefit from treatment, and while data are
lacking in this area, it would be hypothesized that rural
Drug therapies, particularly Methadone Maintenance,
clients also experience significant clinical and cost effective
have also been widely studied and shown to be effective in a
variety of settings. These pharmacotherapies may alsoinclude counseling sessions, groups, or other medical care
in order to stabilize patients with opiate dependence. This
Model treatments
treatment is provided in specialized centers, and few of
There are numerous treatment and prevention programs
these are easily available or accessible to rural clients.
that are being widely used and have been studied. For
The pros and cons of using any of these science-based
example, three treatments for alcohol problems, funded by
treatments in rural settings should be considered.
the federal government, are used in Project MATCH. The
1. Training and research are needed for practitioners to
efficacy of these three psychological approaches to treat-
learn the interventions and to carry out the treatments
ment has been studied in great depth since the late 1980’s.
faithfully and as intended (sometimes known as “treat-
Each of the approaches has been shown to have sustained
ment adherence” research). This can be costly in terms of
effects over one year or longer in an impressive range of
both time and money. However, it would provide the state,
patient populations, including males and females, ethnic
researchers, and treatment center staff with quantifiable
minorities, outpatient versus aftercare treatment, clients
results about how, and if, their programs are working.2. Barriers, such as transportation and stigma, may play a
larger role in treating clients in rural areas. Approaches
tion at the school or community level over several years.
that attempt to remove barriers, either through providing
Creating Lasting Family Connections offers a family
transport or other material supports or providing commu-
strengthening, substance abuse, and violence prevention
nity education about treatment for alcohol and drug
model. Program results, documented with children 11 to 15
problems as a gift given to family and friends (rather than
years, showed significant increases in children’s resistance
weakness or stigma) can be compared to groups of clients
to the onset of substance use and reductions in use of
alcohol and other drugs. The program seems to focus on
3. Many of the large scale studies reviewed offer indi-
resiliency issues, and includes the entire family rather than
vidual treatment sessions, which can be too costly to
just the individual child. However, it may be more difficult
implement in many centers. Individual sessions may work
to recruit and retain families, when compared to interven-
better than group sessions, although smaller centers may
tions that reach children in school settings. The plus for
find it difficult to provide such a wide array of approaches
rural communities would be that family oriented prevention
due to limited resources and staff. However, this question
may ultimately foster more large scale changes, including
has not been researched extensively. Rural centers that
less use of more expensive services, such as drug and
adapted a program, turning it into a group format, could
collect outcome data to see if these more efficient group
Another program that focuses on the family would appear
sessions translate into behavior change. In this case, the
to be far less costly to implement. Family Matters is a home-
cost outlay is not too expensive given that many centers
based program designed to prevent tobacco and alcohol use
do have chart data that would include drug testing results
in early adolescence. The program is delivered through four
for participating clients and could review those data to
booklets. These are mailed to the home and then health
educators make follow-up telephone calls to parents. Thebooklets include readings and activities designed to help
Prevention programs
families explore general family characteristics and family
The Substance Abuse and Mental Health Services Admin-
tobacco- and alcohol-use attitudes and characteristics that
istration (SAMHSA) published several monographs regard-
can influence adolescent substance use.
ing substance abuse prevention programs (USDHHS/
Although rural communities appear to use computers and
SAMHSA, 2002) and has created a website providing
the internet less frequently, those numbers are likely to
information about model programs and the criteria used to
increase in the future. One step up in terms of sophistication
and technology is the Parenting Wisely intervention. This is
All SAMHSA prevention programs that have been
a self-administered, computer-based program teaching
implemented in rural settings were reviewed. A few of these
parents and 9- to 18-year-old children skills to combat risk
appeared to have possibilities for rural Pennsylvania
factors for substance use and abuse. The interactive and
communities. One program, Across Ages, is a school and
nonjudgmental CD-ROM format accelerates learning, and
community-based drug prevention program aimed at youth
parents can use new skills immediately. The program has
9 to 13 years. The goal is to strengthen bonds between
shown positive results regarding avoidance or reductions in
adults and youth and create opportunities for positive
community involvement. The program pairs older adult
One model program, developed in Pennsylvania, was
mentors (age 55 and above) with young adolescents. Given
aimed at a very specific population and may not be ideal for
that Pennsylvania has a significant aging population, a
the general population or rural areas where privacy issues
program like this might be quite feasible and desirable. One
may be a significant concern. Trauma Focused Cognitive
warning from the creators of the program was that adoles-
Behavior Therapy (TF-CBT) is designed to help children,
cents should only be paired with adults they do not already
youth, and their parents overcome negative effects of
traumatic life events including child sexual or physical
All Stars™ is a school- or community-based program
abuse; traumatic loss/death of a loved one; domestic,
intended to delay and prevent high-risk behaviors in middle
school, or community violence; and exposure to disasters. It
school-age adolescents, including substance use, violence,
integrates cognitive and behavioral interventions with
and premature sexual activity. The emphasis is on fostering
traditional child abuse therapies. The focus is on enhancing
development of positive personal characteristics. All Stars
children’s interpersonal trust and empowerment and
includes nine to 13 lessons during its first year, and seven to
targeting any Posttraumatic Stress Disorder (PTSD) symp-
eight booster lessons in its second year. The program is
toms as well. Significant reductions in alcohol and sub-
based on strong research that has identified the critical
stance use were seen as a byproduct of the intervention.
factors that lead young people to begin experimenting with
In summary, there are a large number of both treatment
substances and participating in other high-risk behaviors.
and prevention intervention methods which are science-
Given the positive outcomes found with this program, it
based and considered to be effective. However, it is impor-
would appear to be a good alternative to DARE. However, it
tant to note that, to date, almost none of these interventions
may be cost and time intensive to implement an interven-
have been researched in rural areas, including Pennsylvania.Substance Abuse in Rural Pennsylvania: Present and Future
This is one key area where the state could be collecting data
and Alcohol Advisory Council, a Student Assistance
to determine how best to use the methods in rural settings.
Program, and a Comprehensive K-12 Tobacco, Alcohol, andOther Drugs Curriculum.Effective treatment and prevention strategies for
To summarize, there have been a handful of studies
rural Pennsylvania
produced on effective treatment and prevention strategies
Overall, the trend in treatment strategies in rural Pennsyl-
for rural Pennsylvania, but there are some problems inherent
vania is toward collaborative efforts between governmental
in predicting trends from such scant research. Anecdotal
and private organizations to provide integrated treatment
support, generally in the form of case studies or simple
and prevention strategies. For example, Zielinsky (1995)
evaluation studies of program effectiveness, lack the
proposed an Intensive Outpatient Vocational Rehabilitation
methodological and analytic rigor that is used to character-
Program (IOVRP) for residents of Fayette County. IOVRP,
ize interventions as effective or not.
which was designed to holistically address the intertwinedissues of acquiring gainful employment and recovery from
substance abuse, is especially promising because it is
To receive state and federal substance abuse treatment and
vocationally based. To address barriers to treatment such as
prevention funds, counties in Pennsylvania are required to
transportation, decreased funding, and availability of
establish SCAs, which are responsible for program planning
services, the designers of IOVRP formed a collaboration
and administration of funded grants and contracts. The SCA
with the Fayette County Drug and Alcohol Commission,
system is governed by the Bureau of Drug and Alcohol
Goodwill Industries, and the Office of Vocational Rehabili-
Programs (BDAP). Some of the state’s 67 counties have
tation to provide individual and group therapy,
merged to share administrative costs and resources, referred
psychoeducation, and vocational training, at a centralized
to as joinders, resulting in the establishment of 49 SCAs.
SCAs are the primary contractor/or grantee for state and
Another program that exemplifies the collaborative and
federal allocated funds from BDAP. BDAP allocates funds to
integrated movement of substance abuse treatment in rural
the SCAs through two mechanisms. The first is based on
Pennsylvania was conducted by Pinter (1995) in
county population data and constitutes the majority of state
Northumberland County. Pinter proposed Project SWAP
and federal funding provided to the counties. The second is
(Seniors With Addiction Problems) as an interagency effort
through requests for applications (RFAs) in which BDAP
to: promote effective identification and treatment of seniors
identifies critical populations or important service needs
with additional problems living in Northumberland County,
across the state, and through grants, attempts to address
conduct outreach substance abuse education to isolated and
these issues. In most counties D&A education, prevention,
stay-at-home seniors, and foster a concise and effective
intervention, and treatment services are provided by
referral system among collaborating agencies. Staff members
independent facilities under contracts with the SCAs (BDAP,
of the local Area Agency on Aging were trained to make
referrals to the Northumberland County Single Authority for
Because the SCAs are the county’s extension of the state’s
drug and alcohol treatment that was provided in-home to
D&A programs, they represent the intersection between the
avoid the stigma that accompanies going to a psychological
state’s objectives and goals and the local service needs of
clinic. Prior to the implementation of Project SWAP,
each county. Therefore, the research team surveyed SCA
virtually none of the elderly in Northumberland County
members from Pennsylvania’s rural counties to garner
were identified as potential substance abusers. The results of
information about the D&A service needs of these commu-
this study indicate a substantial increase in referral and
nities and the extent to which the state’s D&A programs
treatment of elderly substance abusers.
There have also been prevention strategies that have
The researchers mailed surveys to 33 SCAs that have
received support for use in rural Pennsylvania. For example,
authority in rural counties of Pennsylvania. The SCAs, in
Thompson (1997) describes a Community Outreach Project
turn, distributed the surveys to their members. Of the 33
that was implemented by the Tussey Mountain School
rural SCAs that received the surveys, 19 different SCAs
District in Bedford County. In this published program
(57.6 percent) responded. Eighty-two individual surveys
evaluation, the local school district served as the facilitator
were received from SCA members with the number of
for an interagency collaborative that was gathered to
respondents from each SCA ranging from one to 11. The
provide educational and prevention services to identified
mean number of surveys received from responding SCAs
youth. The school district used data gathered from the
was 2.75. Respondents were from SCAs across all geo-
Primary Prevention Awareness, Attitudes, and Usage Scales,
which was administered to 7th to 12th grade students. Upon
Two major themes stand out from the review of the SCA
review of the various intervention services available to
survey: first, barriers exist to substance abuse prevention
students, the school district was able to identify many
and treatment in rural areas. For example:
successful programs including a Community/School Drug
• Close to half of the respondents did not believe therewere a sufficient number of continuing education pro-
grams directed toward prevention and treatment issues in
Other key observations
• When asked about changes in the numbers of clients
• About 32 percent of respondents believe that BDAP does
treated over the last two years for specific drugs, most
not show sufficient commitment to rural substance abuse
SCA respondents reported an increase in clients treated
for methamphetamine (59 percent), cocaine (64 percent),
• About 44 percent of respondents believe that BDAP
oxycontin (79 percent), heroin (78 percent), prescription
funding is inadequate for prevention needs;
drugs (56 percent), and polydrug/multiple substance (62
• About 57 percent of respondents believe BDAP funding
• 83 percent of respondents believed that D&A abuse and
• 39 percent of respondents believe that state funding for
dependence will increase in their community in the next
D&A prevention and treatment is biased against rural
two years while 2 percent believed it would decrease and
• About 51 percent maintain the quantity of substanceabuse treatment is below that seen in urban areas;
• About 48 percent believe that funding for D&A services
According to the National Survey of Substance Abuse
Treatment Services (N-SSATS), on a typical day in 2004,
• Almost 49 percent disagreed with the statement that
there were approximately 38,000 clients enrolled in
D&A dependence was considered a healthcare priority by
substance abuse treatment in Pennsylvania. This included
both public and private facilities across the state. About 72
• About 57 percent do not believe that treatment and
percent of the centers were private non-profits, 25 percent
prevention programs developed for urban populations
were private for-profit facilities, and the remainder included
Veterans Affairs and state and local government facilities,
• 44 percent believed their rural location represented a
for a total of 465 centers. The majority of facilities are
barrier to finding qualified treatment employees in their
clustered in larger, more urban areas, as can be seen in
Figure 1. For the 48 rural counties in Pennsylvania, the
• Respondents ranked the following as impediments to
number of available centers ranged from zero in Snyder
D&A treatment within their communities - stigma and
county to 13 in Mercer County. The primary treatment
financial burden (26 percent), rural culture (20 percent),
modality offered is outpatient (78 percent), followed by
lack of access to available services (17 percent), and
residential and inpatient services. About 50 percent of
clients in Pennsylvania are being treated for both alcohol
The second major theme from the survey was the uncer-
and drug problems, suggesting that, throughout the state,
tainty of the respondents regarding key questions related to
polydrug use has become the most common reason for seeking
prevention and treatment services within their counties and
the adequacy of funding for those programs. Most notably:
The number of clients served in rural counties over a one-
• 44 percent of respondents were unsure of whether
year period (2004) was also quite variable, with a low of 10
funding and programs from BDAP have changed to meet
clients in Forest County to a high of 1,708 total admissions
• 42 percent were unsure about BDAP’s commitment to
To learn more about staffing and experiences of rural
centers and the resources available to staff to meet the needs
• 35 percent were unsure if the funding provided by BDAP
of their communities, the researchers surveyed rural treat-
is adequate to meet their prevention needs;
ment personnel. The survey was mailed to all known
• 24 percent were unsure if BDAP funding for treatment is
treatment centers (for the year 2005) in 21 of the 48 rural
Pennsylvania counties. The counties were chosen to reflect
• About 46 percent were unsure if BDAP funding based on
all the rural regions across the state.
A packet of 15 surveys (to allow for differences in staff
• 46 percent were unsure if the allocation of state funds for
size and lost or misplaced surveys) was mailed to the
D&A prevention and treatment were biased against rural
director of each treatment program, along with a cover letter
explaining the project and asking the director to complete
• 59 percent were unsure if RFAs have been effective in
the survey and to share it with treatment staff members.
directing funds towards critical populations that are found
Surveys were returned from 29 of the 80 centers, for a
• BDAP has designated several goals to fulfill its mission
Data from the surveys were analyzed in one large group
in developing a statewide plan for addressing D&A
(n=95) as there were no significant variations by county
dependence and abuse, and many respondents were
regarding the demographics of treatment staff, and analyz-
unsure as to whether they are meeting these goals.
ing by individual centers might compromise the confidenti-ality of the participants.Substance Abuse in Rural Pennsylvania: Present and Future
In general, the rural Pennsylvania providers who re-
• Offering mobile therapy, similar to home or commu-
sponded to the survey tended to have the following charac-
nity visits provided by the Visiting Nurses Association,
teristics: female; white; college educated; not doctors,
psychologists or social workers; credentialed in addiction
• Widening the community net by educating physi-
counseling; in the field for six years or less; at their current
cians, clergy, and mental health providers about routine
center for three years or less; attempt to deliver a very wide
array of services and treatments; committed and hard
• Offering bibliotherapy (readings and workbooks on
working despite lack of funding and other resources; and
addiction or prevention) to clients by delivering
familiar with and use evidence-based treatments.
materials or videotapes/DVDs and other home study
This group also tended to have lower salaries, statewide,
compared to other health service professions, such as
• Using Internet resources where clients would “meet”
nursing, occupational therapy, and other professions based
online, attend support groups, and receive
in hospitals or local health clinics.
5. Confidentiality, stigma and stoicism are important
issues in rural areas, based on the comments provided byboth SCA and treatment center survey respondents. Publiceducation and interventions may need to be designed to
Based on the review of trends, research literature and
address specific cultural issues within each community, as
survey data, the researchers offered the following consider-
a one-size-fits-all approach may not be successful.
1. Statewide data for both rural and urban areas on
• Enlisting “community experts” who are in recovery
outcomes assessment and cost-effectiveness are needed.
from alcohol or drug problems, and willing to provide
The data should include alcohol and drug use measures
public health information and referrals on an informal
and at least one-year of follow-up. Undertaking this
project, and comparing rural versus urban areas would
• Using treatment centers and support groups, such as
make Pennsylvania a model state in terms of its approach
Alcoholics Anonymous, more often if they are housed
to alcohol and substance abuse treatment and prevention.
with other types of medical offices, businesses, reli-
2. Pennsylvania, beginning with BDAP, should consider
gious or spiritual centers, or even shopping malls
viewing rural as a demographic variable, such as gender
(McLellan, O’Brien, Lewis, & Kleber, 2000);
and ethnicity. Statistical comparisons of rural versus
• Presenting alcohol or substance use services to
metropolitan areas or rural versus urban clients are
individuals in the community as a positive step for
lacking in the research literature and in statewide reports.
It would be important to look across age groups as well.
6. Attracting and retaining quality staff at treatment
For example, a focus on adolescents and young adults
centers is critical. As some areas of the state have been
may aid in later prevention efforts, but Pennsylvania also
designated as medical shortage areas, a similar approach
has an aging population. Therefore, it will be critical to
could be advocated regarding the training and retention
collect data across life spans. Community specific data
may also assist BDAP and the state in forming initiatives
7. Continuing education is important for staff. Rural
to target specific problem areas or special populations.
treatment directors indicated their desire to offer continu-
3. The use of evidence-based, empirically supported
ing education as incentives; however, they had no budget
“model” treatments and prevention programs should
allocation to fund the idea. Survey respondents also felt
continue to be encouraged. However, both SCA members
that more continuing education information should be
and rural treatment staff reiterated in their survey re-
sponses that it is often not all clear how well and how
8. More partnerships with universities would be benefi-
easily many model programs - generally developed in
cial. The state should encourage colleges and universities
more urbanized areas - translate to rural settings. It also
to become more involved in their community’s treatment
unclear, based on the data collected through this research,
and prevention system in positive ways. There is a
if practitioners truly adhere to these generally manual-
substantial subset of college and university faculty who
possess expertise in substance abuse issues, epidemiol-
4. Accessibility and transportation to alcohol and drug
ogy, medical research, and the economics of cost effec-
abuse services or prevention programs appear to be major
tiveness and healthcare utilization models. These experts
impediments for clients. Rural centers need both funding
should be encouraged to contribute to rural programs by
and creativity to deal adequately with these issues.
aiding in study design, grant writing, data analysis and
many other activities. Encouraging and perhaps providing
• Piggybacking on existing transportation within a
a jump-start to long-term partnerships between these
entities may prove useful and cost effective.
9. Consider expanding the buprenorphine (pharmaco-
12. Community-based mutual support groups such as
therapy for opiate dependence) program in rural areas as
Alcoholics Anonymous are available in most rural commu-
access to other resources, such as methadone mainte-
nities, although there are generally fewer of these groups
nance, is extremely limited. The state may consider
when compared with urban settings. Given that the national
funding research that looks specifically at this treatment,
overall trend is toward treatments that are as brief as
how best to recruit physicians in rural areas to join the
possible, with only the most severe problems requiring
program, and to employ standardized methods to assess
inpatient, residential or long term outpatient care, it
the efficacy and cost effectiveness of the approach.
becomes more critical to ensure that rural clients are hooked
10. For opiate dependent clients who do not qualify for
into ongoing community support systems. As these groups
buprenorphine treatment, or do not have that option
are also free, there is no cost to the state of Pennsylvania,
available in their area, referrals for methadone mainte-
the substance abuser or mental health systems in the
nance, methadone detoxification, or naltrexone often
require traveling to another more urban county to receive
13. While it was beyond the scope of this research, it is
treatment. If daily dosing is required, clients may spend
important to note that alcohol and substance use are
up to two to four hours per day traveling for services.
systematic problems involving a wide array of both risk and
Transportation problems and the potential impact on a
protective variables. The treatment and prevention systems,
client’s ability to find or maintain employment are key
discussed in this paper, are only one key aspect. However,
hurdles for rural people requiring opiate treatment
expansion of the drug court model, and the provision of
services. It is not cost effective to provide a methadone or
adequate assessment and treatment services in jail or in
opiate specialty program in every county. However,
prison facilities would also appear to be sound investments.
conflicts could be reduced and clients would be more
The use of a community drug court system generally
likely to remain in treatment if they are able to earn “take
remands clients to the appropriate level of treatment
homes.” This method allows clients to take home one or
services and gauges their progress, avoiding the high
more doses of methadone or other pharmacotherapy
expenses associated with jail or prison stays. Simple
contingent on the clients’ number of abstinent/drug free
environmental changes such as seatbelt usage, server
days. Research on this method indicates it may keep
training for bar employees, taxes on alcohol and cigarettes
clients in treatment longer, and reduces costs.
all seem to reduce usage, increase public safety, or even
11. Study the impact of DUI/DWI programs in rural areas
provide revenue (taxes). All of these aspects must be
in terms of the rate of problem alcohol and drug use,
incorporated into any successful strategy targeting rural
ReferencesAmerican Psychological Association. (2002). The Behavioral Healthcare Needs of Rural Women. Washington, DC.ASAM, (2004). Patient Placement Criteria (ASAM PPC-2R). Chevy Chase, MD.Booth, K., C. Bildner, and R. Bozzo, (2001). Substance abuse and welfare: Recipients in the rural setting. Macro Interna-tional, Rural Welfare Issue Brief, February 2001.
Campbell, C.D., M.C. Gordon, and A.A. Chandler. (2002). Wide open spaces: Meeting mental health needs in underserved
rural areas. Journal of Psychology and Christianity, Vol. 4, p.325-332.
Carroll, K.M. (1998) A comparative trial of psychotherapies for ambulatory cocaine abusers: relapse prevention and
interpersonal psychotherapy American Journal of Drug and Alcohol Abuse, Vol. 15, 338-345.
Commonwealth of Pennsylvania, Bureau of Drug and Alcohol Programs. (2004). Drug and Alcohol Programs Reports.Denning, P. (2000). Practicing Harm Reduction Psychotherapy: An Alternative Approach to the Addictions. New York:
Department of Health and Human Services. (2002). Ensuring solutions to alcohol problems analysis of data in substance
abuse and mental health services administration. National Household Survey on Drug Abuse, 2001, Washington, D.C.
D’Onofrio, C.N. (1997). The prevention of alcohol use by rural youth. In E.B. Robetson, A. Sloboda, G.M. Boyd, L. Beatty,
and N.J. Kozel (Eds.), Rural substance abuse: State of knowledge and issues. Research Monograph (No. 168), Rockville,MD: U.S. Department of Health and Human Services, National Institute on Drug Abuse. 220-245.
Gerstein, D.R., R.A. Johnson, H.J. Harwood, D. Fountain, N. Suter and K. Malloy. (1994). Evaluating Recovery Services:The California Drug and Alcohol Treatment Assessment (CALDATA) General Report. Sacramento, CA: CaliforniaDepartment of Alcohol and Drug Programs.
Harwood, H. (2000). Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, UpdateMethods, and Data. (NIH Publication No. 98-4327). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.Substance Abuse in Rural Pennsylvania: Present and Future
Harwood, H. J., D. Malhotra, C. Villarivera, C. Liu, U. Chong, and J. Gilani. (2002). Cost Effectiveness and Cost BenefitAnalysis of Substance Abuse Treatment: A Literature Review. Rockville, MD: U.S. Department of Health and HumanServices, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Harwood, H. J., D. Malhotra, C. Villarivera, C. Liu, U. Chong, and J. Gilani. (2002). Cost Effectiveness and Cost BenefitAnalysis of Substance Abuse Treatment: An Annotated Bibliography. Rockville, MD: U.S. Department of Health andHuman Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Hayashida, M., A.I. Alterman, T. McLellan, C.P O’Brien, J.J. Purtill, J.R. Volpicelli, A.H. Raphaelson, and C.P. Hall. (1989).
Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcoholwithdrawal syndrome. The New England Journal of Medicine, 320(6): 358-365.
Higgins, S. T., D.D. Delaney, A.J. Budney, W.K. Bickel, J.R. Hughes, F. Foerg, and J.W. Fenwick. (1991). A behavioral
approach to achieving initial cocaine abstinence. American Journal of Psychiatry, Vol. 148, 1218–1224.
Higgins, S. T., A.J. Budney, W.K. Bickel, J.R. Hughes, F. Foerg, and G. Badger. (1994). Achieving cocaine abstinence with a
behavioral approach. American Journal of Psychiatry, Vol.150, 763-769
Marlatt, G. A. and J.R. Gordon (Ed.). (1985). Relapse Prevention: Maintenance Strategies in the Treatment of AddictiveBehaviors. New York: Guilford Press.
McLellan A.T., C.P. O’Brien, D.L. Lewis and H.D. Kleber. (2000) Drug addiction as a chronic medical illness: Implications
for treatment, insurance and evaluation. Journal of the American Medical Association, Vol. 284 (1689 – 1695).
National Drug Intelligence Center and Drug Enforcement Administration. October 2003. Pennsylvania Drug ThreatAssessment Update. Document ID: 2003-S0379PA-001.
National Institute on Drug Abuse. (1998). Cost-Benefit/Cost-Effectiveness Research of Drug Abuse Prevention: Implica-tions for programming and policy. (NIDA Research Monograph 176). NIH, USDHHS: Bethesda, MD.
Pennsylvania Commission on Crime and Delinquency. (2006). 2005 Pennsylvania Youth Survey (PAYS) Final Results.
Available:http://www.pccd.state.pa.us/pccd/cwp/view.asp?a=1390&q=576103.
Pinter, D. (1995). Identification and treatment of senior citizens with addiction problems. Treating Alcohol and Other DrugAbusers in Rural and Frontier Areas. Technical Assistance Publication Series 17. Rockville, MD: Center for SubstanceAbuse Treatment. (DHHS Publication No. SMA 95-3054).
Project MATCH Research Group (1997a). Matching alcoholism treatments to client heterogeneity: Project MATCH
posttreatment drinking outcomes. Journal of Studies on Alcohol, Vol. 58, 7-29.
Project MATCH Research Group (1997b). Project MATCH secondary a priori hypotheses. Addiction, Vol. 92, 1671-1698.Project MATCH Research Group (1998). Matching alcoholism treatments to client heterogeneity: Project MATCH three-
year drinking outcomes. Alcoholism: Clinical and Experimental Research, Vol. 22, 1300-1311.
SAMHSA. (1997). SAMHSA issues recommendations for rural behavioral needs. Alcoholism & Drug Abuse Weekly, Vol. 9 (40), 2-3.Substance Abuse and Mental Health Services Administration. (2005). Results from the 2004 National Survey on Drug Useand Health: National Findings (Office of Applied Studies, NSDUH Series H-28, DHHS Publication No. SMA 05-4062).Rockville, MD.
Substance Abuse and Mental Health Services Administration. (2002). The NHSDA Report: Substance use, dependence or
abuse among full-time workers. National Household Survey on Drug Abuse, 2000. U.S. Department of Health and HumanServices.
Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse, 1995 – 1997.
Unpublished analysis of pooled data by Henrick Harwood.
Thompson, C. (1997). A community outreach project in a rural school district in Pennsylvania. Bringing Excellence toSubstance Abuse Services in Rural Areas.
U.S. Drug Enforcement Administration. (2006) Pennsylvania State Fact Sheet 2006. [On-line]. Available: http://
www.dea.gov/pubs/states/pennsylvania.html.
U.S. Department of Health and Human Services. (1997). Inbringing excellence to substance abuse services in rural andfrontier america (pp. 1-163). Technical Assistance Publication (TAP) Series 20. Rockwall, MD. Retrieved January 21,2005, from http://tie.samhsa.gov/taps/tap20/TAP20.html.
U.S. Department of Health and Human Services. (1997) Technical Assistance Publication (TAP) Series 20. Rockville, MD.
Center for Substance Abuse Treatment. (DHHS Publication No. SMA 97-3134).
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, & National Center for Injury
Prevention and Control. (2002). Injury fact book. Washington, DC.
Willits, F. K., A.E. Luloff, and F.X. Higdon. (2004). Current and Changing Views of Rural Pennsylvania. University Park
PA: Department of Agriculture Economics and Rural Sociology, Pennsylvania State University.
Zielinsky, C. (1995). Intensive Outpatient Vocational Rehabilitation Program. Fayette County Drug and Alcohol Commis-
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